Provider Demographics
NPI:1891776670
Name:DOUGLAS, BRUCE LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:LEE
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 DUFFY LN
Mailing Address - Street 2:
Mailing Address - City:RIVERWOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60015-1729
Mailing Address - Country:US
Mailing Address - Phone:847-405-0511
Mailing Address - Fax:847-405-0512
Practice Address - Street 1:701 14TH ST
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-1409
Practice Address - Country:US
Practice Address - Phone:847-689-0400
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T37050Medicare UPIN
IL523670Medicare ID - Type Unspecified
IL207714Medicare ID - Type Unspecified